title: When to perform lymph node dissection in patients with renal cell carcinoma: a novel approach to the preoperative assessment of risk of lymph node invasion at surgery and of lymph node progression during follow-up.
abstract: OBJECTIVE
  To identify preoperatively patients who might benefit from lymph node dissection (LND).
  
  
  METHODS
  We assessed lymph node invasion (LNI) at final pathology and lymph node (LN) progression during the follow-up for 1983 patients with RCC, treated with either partial or radical nephrectomy. LN progression was defined as the onset of a new clinically detected lymphadenopathy (>10 mm) in the retroperitoneal lymphatic area. Logistic regression analyses were used to assess the effect of each potential clinical predictor (age, body mass index, tumour side, symptoms, performance status, clinical tumour size, clinical tumour-node-metastasis stage, and albumin, calcium, creatinine, haemoglobin and platelet levels) on the outcome of interest. The most parsimonious multivariable predictive model was developed, and discrimination, calibration and net benefit were calculated.
  
  
  RESULTS
  The prevalence of LNI was 6.1% (120/1983 patients) and during the follow-up period, 82 patients (4.1%) experienced LN progression. On multivariable analyses, the most informative independent predictors were tumour stage (cT3-4 vs cT1-2, odds ratio [OR] 1.52, P = 0.05), clinical nodal status [cN1 vs cN0, OR 7.09, P < 0.001], metastases at diagnosis (OR 3.04, P < 0.001) and clinical tumour size (OR 1.14, P < 0.001). The accuracy of the multivariable model was found to be 86.9%, with excellent calibration and net benefit at decision-curve analyses.
  
  
  CONCLUSIONS
  By relying on a unique approach, combining the risk of harbouring LNI and/or LN progression during the follow-up period, we have provided the first clinical presurgery model predicting the need for LND.
authors.affiliation: Department of Urology, San Raffaele Scientific Institute, Milan, Italy. umbertocapitanio@gmail.com
authors.forename: Umberto
authors.initials: U
authors.lastname: Capitanio
authors.forename: Firas
authors.initials: F
authors.lastname: Abdollah
authors.forename: Rayan
authors.initials: R
authors.lastname: Matloob
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.forename: Fabio
authors.initials: F
authors.lastname: Castiglione
authors.forename: Ettore
authors.initials: E
authors.lastname: Di Trapani
authors.forename: Paolo
authors.initials: P
authors.lastname: Capogrosso
authors.forename: Andrea
authors.initials: A
authors.lastname: Gallina
authors.forename: Paolo
authors.initials: P
authors.lastname: Dell'Oglio
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.forename: Andrea
authors.initials: A
authors.lastname: Salonia
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Roberto
authors.initials: R
authors.lastname: Bertini
mesh_terms: D002292:Carcinoma, Renal Cell / Q000556:secondary* / Q000601:surgery*; D018450:Disease Progression; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology* / Q000601:surgery*; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D011300:Preoperative Care; D012189:Retrospective Studies; D018570:Risk Assessment